=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720350879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JCAS2, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2012
-----------------------------------------------------
Last Update Date | 02/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14300 CANTRELL RD STE 10
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72223-4216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-581-3711
-----------------------------------------------------
Fax | 501-679-3711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1142
-----------------------------------------------------
City | GREENBRIER
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72058-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-581-3711
-----------------------------------------------------
Fax | 501-679-3711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN JOE CRUM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 501-581-3711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 15973
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------